For more than a year, inmates at several Alabama penitentiaries committed suicide at the rate of one a month.

One leaped from a dormitory. Several hanged themselves from light fixtures and windows. Another died from injuries after attempting to hang himself from a light fixture by a shoestring - an attempt carried out even as a correctional officer was speaking to him. In one case, prison staff waited more than 30 minutes to cut one inmate down. Security logs were falsified, and security and standard mental health checks were never carried out.

On Saturday, U.S. District Judge Myron Thompson used the stories of these 15 men in a 210-page ruling that found the state’s prison system fails to adequately prevent inmate suicides. Thompson ordered the Alabama Department of Corrections to implement specific steps to address what he called “severe and systemic inadequacies.”

Thompson’s ruling found unsafe crisis cells, inadequate treatment of prisoners in crisis care, inadequate monitoring of suicidal prisoners, inappropriate release of prisoners from suicide watch and inadequate follow-up care. The court also found that prisoners with serious mental illnesses had a higher risk factor behind bars. And when suicides occurred, the cases sometimes received inadequate security or medical reviews.

In his ruling, Thompson made permanent most provisions in an interim suicide prevention agreement between the parties, adopted recommendations from experts for the ADOC and the plaintiffs, and ordered monitoring by the court.

Thompson wrote that the ADOC demonstrated a “pervasive and substantial noncompliance with the interim agreement and other remedial measures that they agreed to implement.”

“The risk of suicide is so severe and imminent that the court must redress it immediately,” Thompson wrote.

Here are the individual inmates’ stories, as set out in the opinion, which illustrate some of the issues the ruling dealt with:

Rashaud Morrissette hanged himself on March 8. He used a belt in the shower of the segregation unit at Fountain Correctional Facility near Atmore. Before Morrissette entered segregation, Thompson wrote, officials didn’t properly screen him to determine if he had a serious mental illness or was suicidal.

Matthew Holmes hanged himself from a light fixture Feb. 14, roughly 12 hours after being transferred from mental health observation to segregation at Limestone Correctional Facility. Despite having twice attempted suicide in 2010, Holmes was not placed on suicide watch. Even though he had a serious mental illness, he was taken to segregation without an assessment. On the day he killed himself, Holmes responded to questions at a screening that he was depressed, had attempted suicide in the past and had recent, serious problems, yet he was still sent to segregation.

Daniel Gentry hanged himself at Donaldson Correctional Facility Residential Treatment Center Feb. 6. Though “making it clear he wanted to die,” Gentry was not placed on suicide watch, even after he stated he was experiencing auditory hallucinations and had asked a correctional officer in January to kill him. After his body was discovered hanging by a bed sheet, correctional officers waited several minutes for medical staff to remove the noose and begin CPR. Doctors testified this case showed officers need first aid training and drills on responding to hanging attempts.

Paul Ford hanged himself from his segregation cell door at Kilby on Jan. 16, less than a month after being released from suicide watch. A year earlier, Ford set fire to his cell and attempted to hang himself. He also cut his wrist while in segregation just a month before his suicide.

Roderick Abrams hanged himself from a vent cover inside his cell at St. Clair Correctional Facility on Jan. 2, the same day he was placed in segregation. Abrams told staff he was suicidal, had safety concerns over gang-affiliated inmates because of his sexuality, and had been treated for stab wounds. Yet he was not placed on suicide watch, and staffing and space shortages prevented him from receiving complete mental health appointments. While in segregation, Abrams wasn’t checked every 30 minutes, as per ADOC policy, but sometimes two hours later. He was discovered more than an hour after the last security check, but officers waited 11 minutes before cutting him down to initiate CPR.

Ryan Rust was discovered in his segregation cell on Dec. 21, 2018, sitting on the floor with a belt around his neck and the other end tied to a bar in his cell window. Earlier that month, he attempted to escape. Though he had been on suicide watch in November, there were no follow-up appointments after his release. He received three separate screenings on two days in December, which shows poor communication among nursing staff.

Kendall Chatter hanged himself Nov. 25, 2018 in a cell in the temporary holding unit at Staton prison, using a sheet tied to the ceiling. He was “intensely yelling and banging on his cell in the immediate lead-up to his suicide,” the order stated. The correctional shift supervisor told an officer to allow him to continue until he got tired and stopped. That supervisor was later reprimanded. Earlier that month, Chatter cut his right wrist, possibly after being sexually assaulted.

Mark Araujo used a sheet to hang himself in his segregation cell at Limestone prison on Nov. 23, 2018. Though requesting mental health treatment and medication in October, he was not examined for almost a month.

John Barker hanged himself from a vent cover in his cell at St. Clair prison Sept. 26, 2018. Barker was housed in segregation for several months prior to his death, despite having been flagged as having a serious mental illness. Again, officers waited six minutes before cutting him down and beginning CPR.

Ross Wolfinger hanged himself in his segregation cell at Fountain prison on Aug. 22, 2018. This came less than a month after cutting his wrist and being placed on acute suicide watch. The night of his suicide, the correctional officer assigned to conduct security checks not only failed to do a single check, the order states, but put false information in his duty log indicated he had carried them out. Again, there was no intervention for about eight minutes to cut Wolfinger down and attempt first aid.

Jeffrey Borden hanged himself June 3, 2018 in his cell on death row at Holman Correctional Facility. No life-saving measures were attempted after his discovery. Borden had been diagnosed with schizoaffective disorder, which can include delusions, hallucinations, disorganized thinking and mania.

Timothy Chumney hanged himself using a bed sheet in his segregation cell in Limestone prison on May 12, 2018. This came one day after being released from MHO, a short-term placement without the same protections as suicide watch. Chumney was released to a housing unit where he had expressed concern for his safety from other inmates, and had already been determined to be a moderate suicide risk.

Robert Martinez hanged himself March 31, 2018 at St. Clair prison. He had been in segregation for more than a year, and had told mental health staff he was “doing real bad” and needed to go to the psychiatric ward. Security checks in his unit were not conducted for at least two hours the day he died. Officers waited 30 minutes before cutting him down after his discovery, a delay that experts called “inexcusable and inhumane.”

Billy Thornton died March 2, 2018 of a head injury after attempting to hang himself by a shoestring in segregation at Holman prison on Feb. 26. In late 2017, Thornton said he wanted to kill himself and was hearing auditory hallucinations of “kill, kill yourself." However, he was placed in MHO rather than suicide watch.

Ben McClure jumped to his death from the top tier of a dormitory at Limestone prison on Dec. 30, 2017. Correctional officers waited for nursing staff to initiate lifesaving measures.

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